Joan is transferred to the CCU. Using tools such as the Scottish Early Warning Scoring (SEWS) charts can identify if patients are becoming less well so that interventions can occur early.
There are many models and tools that incorporate all the different aspects involved in acute nursing care. The patient is at the centre of that care and their needs must be the priority. When considering these needs it may be useful to think of this in terms of the following areas using the SBAR tool. This can be particularly useful when considering acute patients and the need for concise but detailed handovers.
Click on the plus points on the chart below for further explanation.
| SBAR | Nursing care | Rationale |
|---|---|---|
| Situation | Joan’s condition. This will include all relevant issues that Joan is concerned with.
The questions reflect Joan’s relevant issues in that she has had a STEMI, had a delayed transfer but did receive evidence based intervention thrombolysis. It is a critical situation for this 42-year old lady. |
These questions can highlight the issues that require attention. Like the mnemonic discussed previously, tools such as this can focus the situation to allow chunks of information to be obtained. |
| Background | From above, her care includes observations (P, BP, O2Sats, RR, Temperature). All other clinical information required is:
Joan is encouraged to participate in her daily care, and report any episodes of chest pain. |
All of these aspects require consideration in order to provide holistic and patient led care. |
| Assessment | Consideration of your findings will lead to further assessment or review. | Considering your findings and reviewing appropriately will promote holistic focussed care. |
| Recommendation | If review required this should be timely in response to above. | Care may require reviewed and changed many times in acute environment. |
- Respiratory Rate (28): Joan is tachyneoic due to lack of circulating oxygen to the lungs, as a result of pulmonary oedema and increased oxygen demands by the heart.
- SPO2 (90): Joan oxygen saturation levels have dropped due to lack of circulating oxygen due to presence of pulmonary oedema.
- Inspired O2 (40): Should be administered using a venturi mask.
- Temperature (37.5): Joan’s core temperature rise can be a result of the acute cardiac event and inflammatory response. This will require monitoring and observation, however should settle in 24-48 hours.
- Blood Pressure (90/50): Joan is experiencing a period of hypotension due to the acute cardiac event, and reduce cardiac output due to poor pumping action of the left ventricle. It is vital to monitor blood pressure closely to ensure adequate perfusion of other major organs and tolerance to vital secondary medications.
- Heart Rate: Joan is Tachycardic, due to her acute cardiac event. There is an increased workload on the heart due to myocardial ischaemia. This should be closely monitored in order to identify any early signs of deterioration, however should settle with secondary medications.
- Neuro Response: Joan is alert and orientated to her surroundings, according the AVPU scale. (AVPU scale (an acronym from “alert, voice, pain, unresponsive”) is a system by which a health care professional can measure and record a patient’s responsiveness, indicating their level of consciousness. It is a simplification of the Glasgow Coma Scale.
Pulse point
Early warning systems are now implanted internationally with some choosing different acronyms for these. (MEWS, SEWS. FEWS).
They are evidence based tools that highlight any changes when monitoring patient’s vital signs and then this gives them an overall score.
A high overall score indicates the patient is deteriorating, and so is monitored very closely. If the high score is above a certain level, the hospital’s “rescue system” intervenes to help avoid the chance of the patient suffering cardiac arrest – the point at which a “crash call” would be made.
As well as preventing patients becoming critically ill, the system allows the Intensive Care staff who would otherwise respond to crash calls to spend more time in Intensive Care Unit (ICU) with the most ill patients.
Page last reviewed: 10 Jun 2020
